SUMMARY. This is a prospective
study of 20 patients with documented self-inflicted burns out of a total of 564 admissions
treated at the Burn Unit of Farah Royal Jordanian Rehabilitation Center, King Hussein
Medical Center, Jordan over a three-year period from 1 January 1993 to 31 December 1995.
The commonest method used by these suicidal patients was to pour kerosene over themselves
and to set light to it (18 patients out of 20). A high proportion of females (16/20) was
found in this series. Eight patients had previous psychiatric illness and five, all
females, were involved in recent family or marital feuds. The average total body surface
area burned was 48% and the overall mortality rate 70%.

Introduction

Burning is considered to one of the most
violent methods of suicide in the westem world, although it is uncommon. In a British
study it was demonstrated that burning with the intent of suicide by Asian women residing
in Britain was carried out mainly owing to cultural differences and interpersonal
disputes, especially in relation to marriage.'Similar studies elsewhere have shown that
the highest incidence of attempted suicide by burning was among Asian and African women.`
Our study was conducted in order to investigate the magnitude of the problem in our
country (Jordan), to find out which individuals are most prone to this method of suicide,
and to investigate the outcome of self-inflicted burns.

Materials and methods

This is a prospective study of
self-inflicted burns treated at the burn Unit of Farah Royal Jordanian Rehabilitation
Center, King Hussein Medical Center, Jordan, over a threeyear period from I January 1993
to 31 December 1995. This forms part of a continuing audit of all burn
admissions to our unit. Out of a total number of 564 admissions over the period,
twenty patients (3.5%) were positively identified as having attempted suicide by
burning. These patients were analysed with respect to age, sex, method used, place of
burn, psychiatric history, family relations, total body surface area (TBSA) burned, and
outcome.

Results

The commonest method used by suicidal
patients in this series was to pour kerosene over themselves and to set light to it (18/20
patients = 90%). Two patients used domestic gas to cause an explosion. Eighteen
(= 90%) of the suicide attempts occurred at home. A high proportion of females (16/20
= 80%) was found in this series. The mean age for both males and females was 28 yr.
The commonest age group involved was that of young adults, with 12 patients (60%)
between the ages of 15 and 24 yr (Table 1).

Age
distribution(yr)

MaleN° patients

FemaleN° patients

TotalN° patients

<15

0

0

0 (0%)

15-19

2

4

6 (30%)

20-24

1

5

6 (30%)

25-29

0

1

1 (5%)

30-34

0

2

2 (10%)

35-39

0

1

1 (5%)

>40

1

3

4 (20%)

Total

4 (20%)

16 (80%)

20 (100%)

Table 1 - Age and sex distribution of suicidal
burns

Suicidal burns tend to be major injuries
with a high TBSA, as previously reported. The TBSA burned in the suicidal burns in this
series varied from 20 to 95% (average, 48%). Most patients suffered
deep second- and third-degree burns. Head burns (12/20 = 60%) were common in this
group, as in other groups. Four patients also presented inhalation injuries and had to be
ventilated on admission.
The mortality rate for these suicidal burns was 14/20 (70%), compared with 72/544
(13%) for non-suicidal burns treated over the same period at our institution; for
patients with less than 60% TBSA the mortality rate was 7/13 (54%) for
suicidal burns, compared with 48/520 (9%) for non-suicidal burns treated over the
same period. These findings are similar to others in the literature.
The past medical history of all the patients was reviewed. Eight patients (40%) were found
to have a previous psychiatric history; of these, five patients had documented endogenous
depression and three patients were known to have schizophrenia. All the patients were
receiving anti psychotic treatment at tit c I iin c oft I icir at I erupted suicide. Five
patients (25%), all fernalcs, were involved in recent family or marital feuds and one
patient was suffering from post-partum depression. The reiriaining six patients were riot
known to have air prior psychiatric illness, altliou"h y a social problem could not
be excluded (Table II). this series 14 patients (701/,~) (fie(] ill hospital after an
average hospital stay of 12 days. The six survivors had an avera-e stay of 35 days. The
font- pai icrits with associated inhalation in.juries all died.

Previous History

N° patients

Psychiatric illness: Depression

5 (25%)

Psychiatric illness: Schizophrenia

3 (15%)

Family or marital problems

5 (25%)

Post-partum depression

1 (5%)

Unknown (not excluding possible social problems)

6 (30%)

Total

20 (100%)

Table II
- Predisposing factors for suicidal burns

Discussion

A previous psychiatric history aniong
attempted suicidal burns was found to be common, as previously reported. Our series showed
a 40% prevalence ofprevious psychiatric illness among persons atteruptino suicide. Closer
evaluation and assessment for psychiatric patients is advised, particularly ill view of'
the fact that all our psychiatric patients were being treated at the tinic of their burn.
The study also shows that attempted suicide hy burnino is still frequent in out-
society.adult females, because of the dramatic nature of file. incident. A disturbing
finding is that some women with social problems may resort to self-inuitolation as a
inethod of expressing their anger and dissatisfaction at their current social state. These
women do not realize that this nielliod of buriling is a sure way to conninit suicide
because of- tile high TBSA burned and the increased depth of' burns resulting from pouring
kerosene over dicinselves and setting light to it. The high mortality rate for suicidal
burn patients compared with non-suicidal patients, especiili)l, those with less than 60%
TBSA burned, may, also be attributed to the overall state of mine] of tlicse palicilts,
coupled with an unwillingness to survive.
Increased public awareness of the very Serious nalUre of such maJor burns may help to
dissuall, Some. persolls front attempting suicide by burnim, as a nictliod of parasuicidal
behaviour to express a strong point of view.

Conclusions

Burning by kerosene is a comnion,
tradifional and dramatic way of attempting suicide in Jordan. The highest suicide rate was
found among young women. Suicidal burns were found to have a high TBSA and a high
mortality rate compared with other burns of similar magnitude. Increase(] public awareness
that parasuicidal behaviour by burnino has serious consequences and is riot Just a cry
lot- lielp may reduce the incidence of' such cases.

The 1998
Tanner-Vandeput-Boswick Burn Prize of the International burn Foundation was awarded to Dr
Gosta Arturson of Uppsala, Sweden for his outstanding contributions to burn research. Dr
Arturson received $150,000, a plaque and a gold/diamond pin designed by the late Dr J.C.
Tanner.
The Foundation also made a unique Special Award to the late Dr Nelson Picolo of Goiania,
Brazil (1927-1988) in the amount of $100,000 for his contributions to burn care and
prevention in his area of the world. The family of the late Dr Picolo was presented with a
plaque and a gold/diamond pin.
The prizes were awarded with the following motivations: Dr ArtursoD is a unique
surgeon-scientist whose productivity in the understanding of pathophysiology of burn
injury spans his entire professional career of five decades. His consistent meticulous
laboratory investigations in the complex setting of burn injury exemplify the highest
standard of scientific research. This work has been a significant contributing factor to
the remarkable improvement in the survival of burn patients which has occurred during the
past 35 years.
Dr Arturson has also worked extensively in the area of mass burn disaster planning and
management. Dr Arturson is well known throughout the world for his unselfish devotion to
his work and for his humanity. The prize expresses the appreciation and admiration by his
colleagues for the varied accomplishments of this brilliant, unassuming investigator who
has devoted his career to the betterment of burned patients. For this effort he has been
widely honoured by prestigious lectureships and awards. To these is now added the 1998
Tanner-Vandeput-Boswick burn Prize.
In 1968 Dr Picolo organized the first hospital in Brazil devoted entirely to the care of
burn patients. Since then more than 130,000 patients have been treated, using all
practicable advances in care and rehabilitation acquired by Dr Picolo by his regular
attendance at worldwide scientific meetings and frequent visits to prominent burn clinics.
He was the driving force behind the founding of the Brazilian burn Society. His work in
burn care and prevention continued until his death in 1988. This posthumous Special Award
recognizes the unique contributions of Dr Picolo, whose wife and three physician children
carry on his work to this day in the hospital he founded.